Pony parties quote request form

Duty of Disclosure of Material Facts (Duty of Fair Presentation)

A material fact is an important fact about you or your circumstances. Fairpresentation means that you must have disclosed all material facts, matters andcircumstances which you know, which could influence an insurer's orunderwriter's decision to accept your insurance. This also applies to factsthat you ought to know. You must disclose sufficient information to make theinsurers aware that they need to make further enquiries. They can then chooseto accept or decline your insurance. If they accept, they may apply certainterms. The duty of fair presentation is a significant obligation placed uponyou under the contract of insurance. If you fail to meet this obligation, insurers can take various actions in accordance with the Insurance Act 2015.
Title*
Name*

First nameLast name
Full trading name (if applicable)
Address*

Address line 1

Address line 2

City

Postcode
Is the risk address the same as the correspondence address?*

YesNo
Please provide the full risk address
Telephone*
Please enter a valid phone number.Format: 00000 000000.
Email*

Confirmation EmailConfirm email
Website (if applicable)
Date of birth*

DayMonthYear
Is a joint policy required?*

YesNo
Title*
Name*

First nameLast name
Date of birth*

DayMonthYear
Please select the option which best describes your business:*
Please advise your current insurer. Please put NA if not applicable. *
Please advise your current renewal premium. Please put NA if not applicable. *
Annual renewal date (if applicable)
How many years' experience do you have in the equine industry?*
What equine qualifications do you have?*
How long has your business been established? Please indicate if this is a new venture. *
What is your main business activity?*
Please give details of the activities being undertaken: *
Are any other activities carried out?*

YesNo
Please provide full details
Are any other businesses run from the premises?*

YesNo
If yes, please provide full details:
Do you own or lease the premises?*

OwnLease
If lease, do you have a written contract in place with the landlord to stipulate who is responsible for fences/hedges etc?

YesNo
Do you do any work outside of the UK? *
What level of public liability cover do you require?*
What date should your policy commence? *

DayMonthYear
Date
Please state the approximate number of parties/educational visits per year:*
If cover is for a single event, please state the date of the event:

MonthDayYear
Date
How many ponies will you be using at any one time? *
Are the ponies you will be using all owned by you?*

YesNo
Please supply the age, breed, height and sex of each pony you will be using, along with how long you have owned them and details of each ponies experience of these activities: *
How long will each party/session be? *
Will there be a ridden element?*

YesNo
Where will the parties be taking place?*

Own premisesOffsite at third party premisesBoth of the above
Will the parties be taking place within a secure area?*

YesNo
Do any non equestrian activities take place as part of the sessions? If yes, please give details: *
What is the minimum age of session participants? *
Will all children's parent/guardian be present at all times?*

YesNo
Please state the ratio of participants to employees/handlers: *
Please state the ratio of participants to ponies:*
Do you hold a valid licence from your local authority?*

YesNo
Are you aware of your obligations under the Health & Safety Act 1974? (see www.hse.gov.uk)*

YesNo
Do you have a current DBS check?*

YesNo
Do you have an accident report book?*

YesNo
If yes, is it updated if an accident occurs?

YesNo
Are your electrical installations checked and maintained in accordance with current Health & Safety regulations?*

YesNo
Do you have a written Health & Safety with risk assessments in place?*

YesNo
Are your risk assessments reviewed regularly?*

YesNo
Have full risk assessments of the ponies been carried out, with written records kept?*

YesNo
Have any of the ponies ever shown any signs of abnormal behaviour? (for example but not limited to: kicking, biting, bucking, bolting etc.)*

YesNo
If yes, please give full details:
Do you have any employees (paid or voluntary)?*

YesNo
Please note you are legally required to arrange Employers' Liability for paid employees and for paid self-employed persons working under your direction.
If yes, how many?
Please provide your Employer Reference Number (ERN) if applicable:
Please detail below the name, age, experience and qualifications of all staff members below:
Do you have a written staff induction/training records?

YesNo
If you have employees, will the policy holder/owner be present at all times or will the employees run the sessions?
If you have employees, will Personal Protective Equipment (PPE) be provided?

YesNo
If yes, what items will be provided?
Will the PPE be checked regularly with written records of the checks kept?

YesNo
Do you ensure you have sufficient qualified first aid staff available at all times?*

YesNo
Have you communicated all risk assessments to your staff?

YesNo
What is your annual turnover?*
Has any insurer in respect of any of the risks to which this proposal refers, declined to insure you, cancelled or refused to renew your insurance or imposed special terms?*

YesNo
If yes, please provide details:
Have there been any losses suffered, or events occurred which might have resulted in a claim, whether or not claimed for, during the last five years, in respect of any of the activities for which cover is required?*

YesNo
If yes, please provide details:
Have you or any of your officers, business partners or directors, ever been convicted of any criminal offence other than a driving offence or have any non-motoring prosecutions pending? You only need tell us about any convictions that are unspent under the Rehabilitation of Offenders Act 1974.*

YesNo
If yes, please provide details:
Have you or any of your officers, business partners or directors, ever been declared bankrupt or insolvent?*

YesNo
If yes, please provide details:
Have you or any of your officers, business partners or directors, ever been investigated or convicted under the Fraud Act 2006, or equivalent legislation?*

YesNo
If yes, please provide details:
How did you hear about Cliverton? *
If 'other', please state where: *
How would you prefer to be contacted by Cliverton?*

PhoneEmail
Would you like to receive news and updates from Cliverton?*

YesNo
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Not making a fair presentation of the risk, or not advising us of any errors in the information provided may result in a breach of the fair presentation of risk. Depending on the nature of the breach and what would have happened had the information been accurate, the insurer may choose to: 1. Declare your policy void (treating your policy as it had never existed) 2. Change the terms of your policy. 3. Refuse to deal with all or part of any claim or reduce the amount of any claim payment. 4. Cancel your policy. If any of the information within the documents provided is incorrect, you must advise us. We reserve the right to change the terms and conditions, premium or withdraw this quotation.
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Duty of Disclosure of Material Facts (Duty of Fair Presentation)

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